Undergoing Cardiopulmonary Bypass Surgery Research Articles

Relation between antithrombin-III activity and activated clotting time for cardiopulmonary bypass.

Heparin resistance (HR) is observed before cardiopulmonary bypass (CPB), despite with normal antithrombin III (AT-III) levels. The relationships between preoperative AT-III activity and activated clotting time (ACT) after the first heparin dose should be clarified. We retrospectively analyzed the data of 818 patients who underwent CPB surgery, with the initial heparin of 300, 400, and 500IU/kg, between 2017 and 2021. We defined HR as the failure to achieve ACT after the initial heparin dose (Post ACT) of > 480s.There were no significant correlations between the AT-III activity and Post ACT in all patients, including 143 patients with AT-III activity < 80% and 675 patients with AT-III activity of ≥ 80%. Also, there were no significant correlations between the AT-III activity and Post ACT in 74 patients who received heparin of 300IU/kg, in 186 patients with 400IU/kg, and in 339 patients with 500IU/kg. After identifying smoking, HR, activated partial thromboplastin time, fibrinogen degradation products (FDP), and ACT as influencing factors, multiple comparisons using the Steel-Dwass test showed significant difference in FDP and HR among the patients who received heparin of 300IU/kg, 400IU/kg, and 500IU/kg. There is no association between preoperative AT-III activity and ACT after the first heparin administration for CPB, even in different dose of heparin. Rather, the higher the initial UFH dose is, the higher ACT may be, regardless of the AT-III activity.

Population pharmacokinetic modeling of sufentanil in adult Korean patients undergoing cardiopulmonary bypass surgery.

Sufentanil is frequently used as an anesthetic agent in cardiac surgery owing to its cardiovascular safety and favorable pharmacokinetics. However, the pharmacokinetics profiles of sufentanil in patients undergoing cardiopulmonary bypass (CPB) surgery remain less understood, which is crucial for achieving the desired level of anesthesia and mitigating surgical complications. Therefore, this study aimed to develop a population pharmacokinetic model of sufentanil in patients undergoing CPB surgery and elucidate the clinical factors affecting its pharmacokinetic profile. Adult patients who underwent cardiac surgery with CPB and were administered sufentanil for anesthesia were enrolled. Arterial blood samples were collected to quantify plasma concentrations of sufentanil and clinical laboratory parameters, including inflammatory cytokines. A population pharmacokinetic model was established using nonlinear mixed-effects modeling. Simulations were performed using the pharmacokinetic parameters of the final model. Overall, 20 patients were included in the final analysis. Sufentanil pharmacokinetics were modeled using a two-compartment model, accounting for CPB effects. Sufentanil clearance increased 2.80-fold during CPB and warming phases, while the central compartment volume increased 2.74-fold during CPB. CPB was a significant covariate affecting drug clearance and distribution volume. No other significant covariates were identified despite increased levels of the inflammatory cytokines, including IL-6, IL-8, and TNF-α during CPB. The simulation indicated a 30 μg loading dose and 40 μg/h maintenance infusion for target-controlled infusion. Additionally, a bolus dose of 60 μg was added at CPB initiation to adjust for exposure changes during this phase. Considering the target sufentanil concentrations, a uniform dosing regimen was acceptable for effective analgesia.

Determination of Early Diagnostic Biomarkers of Renal Dysfunction After Cardiopulmonary Bypass: miR-21 and miR10a Mediated Postoperative Inflammation

Objective: Acute renal failure (ARF) prevalence is high among patients who undergo cardiopulmonary bypass (CPB), and this condition can only be diagnosed via serum creatinine level (sCr) conventionally within 48 hours. Therefore, we need early novel diagnosis biomarkers to start preventive treatment of ARF. For that reason, we aimed to analyze if plasma miR-21 derived from heart, correlates with kidney- enriched miR-10a during inflammatory IL-6, IL-1β, and TNF-α response in terms of acute renal failure 30 minutes after CPB.&#x0D; Methods: Patients (n=46, Female:8 and Male:38), aged 61.08±9.41, who underwent CPB surgery were included. Blood samples were collected during the pre – and post-CPB (30 minutes after CPB). Demographic data of all cases were collected. Quantification of expression levels of miR-21 and miR-10a was done via quantitative PCR (qPCR). Determination of plasma concentration of relevant cytokines, IL-6, IL-1β, and TNF-α was done via ELISA.&#x0D; Results: The circulating level of miR-21 during post-CPB period (-11.78±6.98) was significantly higher (p≤0.05) than pre-CPB period (-6.55±7.11), but there was no significant change (p&gt;0.05) in the circulating level of miR-10a between pre – (-12.22±3.55) and post-CPB (-11.60±3.36) periods. When we compared the mean ΔΔCt values of miR-21 and miR-10a, downregulation was observed in the expression level of miR-10a (0.62±3.77) whilst the expression level of miR-21 (-5.22±7.25) was upregulated (p≤0.05). The levels of plasma concentration of IL-6 (2.74±2.50 ng/l) and TNF-α (83.63±9.33 ng/l) were increased during post-CPB period (both were ***p

Remote ischemic preconditioning and cognitive dysfunction following coronary artery bypass grafting: A systematic review and meta-analysis of randomized controlled trials.

Postoperative cognitive dysfunction (POCD) is a common neurological issue following cardiopulmonary bypass (CPB)-assisted heart surgery. Remote ischemic preconditioning (RIPC) increases the tolerance of vital organs to ischemia/reperfusion injury, leading to reduced brain injury biomarkers and improved cognitive control. However, the exact mechanisms underlying RIPC's neuroprotective effects remain unclear. This systematic review aimed to explore the hypothesis that RIPC lowers neurocognitive dysfunction in patients undergoing CPB surgery. All relevant studies were searched in PubMed, ScienceDirect, EBSCOhost, Google Scholar, Semantic Scholar, Scopus, and Cochrane Library database. Assessment of study quality was carried out by two independent reviewers individually using the Cochrane Risk of Bias (RoB-2) tool. Meta-analysis was performed using a fixed-effect model due to low heterogeneity among studies, except for those with substantial heterogeneity. A total of five studies with 1,843 participants were included in the meta-analysis. RIPC was not associated with reduced incidence of postoperative cognitive dysfunction (five RCTs, odds ratio [OR:] 0.79, 95% confidence interval [CI]: 0.56-1.11) nor its improvement (three RCTs, OR: 0.80, 95% CI: 0.50-1.27). In addition, the analysis of the effect of RIPC on specific cognitive function tests found that pooled SMD for RAVLT 1-3 and RAVLT LT were -0.07 (95% CI: -0.25,012) and -0.04 (95% CI: -0.25-0.12), respectively, and for VFT semantic and phonetic were -0.15 (95% CI: -0.33-0.04) and 0.11 (95% CI: -0.40-0.62), respectively. The effect of RIPC on cognitive performance in CABG patients remained insignificant. Results from previous studies were unable to justify the use of RIPC as a neuroprotective agent in CABG patients.

Optimal timing of SARS-CoV-2 vaccination prior to cardiovascular surgery under cardiopulmonary bypass.

mRNA vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) became common. We investigated the optimal timing for inoculation against SARS-COV-2 in the candidates for cardiac surgery under cardiopulmonary bypass (CPB). In 100 patients with preoperative vaccination, who underwent CPB surgery between July 2021 and February 2022, the IgG against the receptor binding domain (RBD-IgG), with a threshold of >100 binding antibody unit (BAU)/mL for adequate immunity, was measured. The vaccines, including 87 BNT162b2 (Pfizer/BioNTech) and 13 mRNA-1273 (Moderna), were inoculated at 98.8 ± 59.4 days before surgery. The median RBD-IgG titers before surgery, 1 day after surgery, and 1 month after surgery were 166.8, 100.0, and 84.0 BAU/mL, respectively. The standby interval (SBI) from the vaccination to the surgery showed a significantly negative correlations with the RBD-IgG titer before the surgery (p < 0.001). A cut-off SBI for RBD-IgG >100 BAU/mL before surgery was <81 days with a sensitivity of 76%, specificity of 62%, and area under ROC value of 0.73 (p = 0.03). The patients with SBI <81 days (n = 48) had significantly higher RBD-IgG (>100 BAU/mL) than those with SBI ⩾81 days (n = 52) at all perioperative periods. Although 40% of the RBD-IgG titers reduce 1 day after CPB surgery, the patients who received the SARS-COV-2 vaccination within an 81-day window prior to the surgery maintained a desirable RBD-IgG level, even up to 1 month after surgery. It may be important to schedule the surgery no later than 81 days after the vaccination.

Contributing factors to heparin resistance during cardiopulmonary bypass.

Since the risk factors for heparin resistance (HR) before cardiopulmonary bypass (CPB) have not been fully clarified, this study investigated the contributing factors for HR after the initial unfractionated heparin (UFH) dose of 500IU/kg. We retrospectively analyzed the data of 371 patients who underwent CPB surgery, with the initial UFH dose of 500IU/kg, between May 2017 and December 2021. We defined HR as the failure to achieve activated clotting time (ACT) of > 480s after the initial UFH dose of 500IU/kg. HR was observed in 36 patients (9.7%) (HR group), while HR was not observed in 335 patients (control group). The HR group included significantly more patients with preoperative use of UFH, with significantly higher white blood cell counts, fibrinogen, fibrinogen degradation products, D-dimer, and C-reactive protein, and lower hemoglobin and albumin. The multivariable logistic regression analysis identified albumin (OR: 3.09, 95% CI 1.3504-7.0845, p = 0.0075) and fibrinogen (OR: 0.99, 95% CI 0.9869-0.9963, p = 0.0003) as independent predictors for HR. Using the Youden index, the cutoffs of albumin and fibrinogen were calculated as 3.8g/dL and 303mg/dL, respectively. The receiver operating characteristic curves showed the predictive performance of albumin (area under the curve (AUC): 0.78, sensitivity: 65%, specificity: 81%) and fibrinogen (AUC: 0.77, sensitivity: 56%, specificity: 88%). The incidence of HR after the initial UFH dose of 500IU/kg was 9.7%. The preoperative albumin < 3.8g/dL and fibrinogen > 303mg/dL were independent predictors for HR.

A Comparison between Thromboelastography and Conventional Clotting Tests in Pediatric Patients After Cardiopulmonary Bypass Procedure.

The coagulation system is more complicated in younger infants because the hemostatic system is not completely mature before 6 months. There is confusion among pediatricians to choose conventional coagulation tests and thromboelastography (TEG) to evaluate coagulation function for infants in major surgery. This study was undertaken to perform a comparison between the two methods for pediatric patients who underwent cardio-pulmonary bypass (CPB) surgery. Infant patients who underwent CPB surgery were divided into two groups - younger group (age < 6 months old, n = 72) and older group (age from 6 months old to 12 years old, n = 76). Prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), and fibrinogen (Fib) of conventional coagulation tests and reaction time (R-time), speed of fibrin building up (ɑ-Angle), clot conformation time (K-time), maximum colt amplitude (MA) of TEG results before and after CPB, as well as increasing or decreasing rate of all the values after CPB, were compared between the two groups. Postoperative transfusion details were summarized. PT, APTT, R-time, and K-time markedly increased (p < 0.05) and Fib, ɑ-Angle, and MA decreased (p < 0.05) after CPB in both groups. The younger group had a much higher rate of postoperative transfusion with suspended red cells (54.17% vs. 17.11%), fresh frozen plasma (29.17% vs. 9.21%), cryoprecipitate (9.72% vs. 1.32%), and apheresis platelet (5.56% vs. 0) than the older group. Increasing rate of R-time and K-time and decreasing rate of ɑ-Angle and MA after CPB in the younger group were significantly higher than that in the older group (p < 0.01), whereas no significant differences were observed in conventional coagulation tests (p > 0.2). TEG was more sensitive than conventional coagulation tests in response to variation of coagulation function for younger infants after major surgery.

Continuous electroencephalography (cEEG) in infants with congenital heart disease (CHD).

Neonates with congenital heart disease (CHD) undergoing cardiopulmonary bypass (CPB) surgery have increased risk of impaired neurodevelopmental outcomes secondary to brain injury. This study aims to characterize pre- and post-operative continuous EEG (cEEG) patterns to detect abnormal cerebral activity in infants with CHD and investigate whether an association exists between the degree of encephalopathy in pre- and post-operative cEEG. This retrospective cohort study conducted between 2010 and 2018 at a tertiary hospital in Cleveland, OH included infants with CHD with cEEG monitoring, who underwent CPB surgery within first6 months of life. Study included 77 patients, of which 61% weremales who were operated at median age 6 days. Pre-operatively, 69% and 87% had normal cEEG and sleep-wake cycles, respectively. Post-operatively, 80% had abnormal cEEG. Longer circulatory arrest time and CPB were associated with lack of continuity (p 0.011), excessive discontinuity (p 0.007) and prolonged inter-burst interval (IBI) duration (p value < 0.001). A significant association existed between severity of encephalopathy in immediate and 24-h post-operative period (p value < 0.001). More than 80% of neonates with CHD have abnormal post-operative EEG. Longer circulatory arrest time and CPB were associated with lack of continuity, excessive discontinuity, and prolonged IBI duration on post-operative EEG. This study shows that majority of neonates with congenital heart disease (CHD) have normal pre-operative EEG with a continuous background and normal sleep-wake cycles. Also, 80% of neonates had abnormal post-operative EEG. Longer duration of arrest time and bypass time was associated with lack of continuity, excessive discontinuity, and prolonged IBI duration during post-operative EEG monitoring. These findings will help clinicians when counseling parents in the intensive care unit, risk stratification, and long-term neurodevelopmental monitoring in these high-risk patients.

The Effect of Prophylactic Intravenous Amiodarone Administration on Reperfusion Ventricular Fibrillation in Patients With Left Ventricular Hypertrophy Undergoing Cardiopulmonary Bypass Surgery: Protocol for a Randomized Double-Blind Clinical Trial

Ventricular fibrillation (VF) is a common arrhythmia that occurs after the release of aortic cross-clamp (ACC) in patients undergoing cardiopulmonary bypass (CPB) surgery. Repeated defibrillation and long duration of VF could increase myocardial injuries. In patients with left ventricular hypertrophy (LVH), VF is easier to occur and more difficult to be terminated. Amiodarone, known as class III antiarrhythmic agent, has the prominent properties of converting VF and restoring the sinus rhythm. Before ACC release, administration of amiodarone has been confirmed useful to reduce occurrence of VF. However, few studies are focused on the effect of amiodarone before ACC release on reducing VF in patients with LVH. This study aimed at determining the efficacy of prophylactic intravenous amiodarone administration on reperfusion VF after release of ACC in patients with LVH undergoing CPB surgery. This will be a prospective, randomized, double-blind, placebo-controlled trial. The trial will enroll 54 patients with LVH aged 18-75 years who will undergo CPB surgery. All eligible participants will be randomly allocated to either the amiodarone or placebo group by using the block randomization in a 1:1 ratio. The primary end point will be the incidence rate of VF 30 minutes after ACC release and be assessed using the Fisher exact test. All data will be analyzed in accordance with the intention-to-treat principle. The study began in August 2022, and the data collection will take place for the next 2 academic years. As of this writing, 21 participants have already been recruited for the study. With this trial, we are hoping to demonstrate that prophylactic infusion of amiodarone before ACC release could reduce the occurrence of reperfusion VF in patients with LVH. ClinicalTrials.gov ChiCTR2000035057; https://www.chictr.org.cn/showprojen.aspx?proj=57145. DERR1-10.2196/40115.

Efficacy of the Hepcon System in Reducing Hemorrhagic and Thrombotic Complications in Antiphospholipid Syndrome Patients Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass

Introduction: Patients with Antiphospholipid Syndrome (APS) undergoing cardiopulmonary bypass (CPB) surgery are at increased risk for thrombotic and hemorrhagic complications. Heparin concentration during CPB is typically monitored by the activated clotting time (ACT), however, antiphospholipid antibodies have the potential to alter the baseline ACT. The Hepcon Hemostasis Management System (HMS) utilizes an individualized heparin dose-response curve to estimate free plasma heparin levels and has been shown to correlate well with anti-Xa levels. The purpose of this study is to evaluate the efficacy of Hepcon HMS in reducing thrombotic and hemorrhagic complications in APS patients undergoing cardiac surgery requiring CPB in a large cardiac surgery referral center. Herein, we report the largest cohort study to date of APS patients monitored with Hepcon HMS during CPB surgery. Methods: We performed a retrospective study of APS patients who underwent cardiac surgery requiring CPB at the Cleveland Clinic between April 2013 and July 2020. Two sets of antiphospholipid (APL) antibody labs spaced at least 12 weeks apart, or one set of APL labs in addition to historical elevated antibodies must have been present for inclusion. Vascular thrombosis or pregnancy morbidity (defined by revised Sapporo criteria) must have been documented for inclusion. The Hepcon HMS was utilized for intraoperative (intra-op) anticoagulation monitoring at the discretion of the cardiothoracic surgeon, anesthesiologist, and perfusionist. Data including blood product administration, thromboembolic, and major hemorrhagic complications were collected from the intra-op period through post-operative (post-op) day 30. Major hemorrhage was defined using the International Society on Thrombosis and Haemostasis criteria. The primary endpoint was the composite rate of thromboembolic or hemorrhagic complications per surgical case in patients monitored by Hepcon HMS vs. patients monitored by point-of-care-ACT. Secondary endpoints were median volume of chest tube output and packed red blood cell (PRBC) transfusion within the first 3 post-op days. Continuous and categorical variables were analyzed using Wilcoxon rank sum test and Fisher's exact test, respectively. Results: Of 201 screened patients, 43 met inclusion criteria. Of the 43 patients, 20 (47%) patients were monitored using Hepcon HMS during CPB surgery while 23 (53%) were monitored using point-of-care ACT. The two groups did not have a statistically significant difference in baseline characteristics including gender, comorbidities, age, and pre-op ACT, body mass index, creatinine, hemoglobin, and platelet count. The presence of triple positive APL antibody profile was statistically significant between the two groups with 11 such patients in the Hepcon HMS group and 2 such patients in the ACT group (p = .001). Surgical characteristics including total pump time, total cross clamp time, procedure type, and intra-op PRBC transfusion were not significantly different between the two groups. For the primary endpoint, there was no statistically significant difference between the Hepcon HMS and ACT groups (Hepcon HMS 6/20 [30%]; ACT 7/23 [30%]; p = >.99). For the secondary endpoints, there was no statistically significant difference in median post-op chest tube output (780mL vs. 850mL; p = .88) and median post-op PRBC transfusion (1 unit vs. 0 unit; p = .28) between the Hepcon HMS and ACT groups, respectively. Subgroup analysis of patients with triple positive APL antibody profile did not show a statistically significant difference in rate of complications between those monitored with Hepcon HMS vs. those monitored by ACT (27% vs. 50%, p = .54). Conclusion: In this largest to date cohort study of APS patients who underwent CPB surgery, there was no difference in the composite outcome of thrombotic or hemorrhagic complications in patients monitored by Hepcon HMS vs. those monitored by ACT. Both groups had a high rate of complications, which highlights the high-risk nature of this patient population. Prospective randomized trials are warranted to better define optimal heparin concentration monitoring during CPB surgery in APS patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Better cardioprotection in atrial septal defect patients treated with cardiopulmonary bypass beating heart technique without the application of aortic cross clamp

Background and objectives: Creatine phosphokinase-myocardial band fraction (CPK-MB) and cardiac troponin I (cTnI) are cardiac specific biochemical markers which are raised in myocardial ischemia. The aim of this study was to determine cardiac injury by comparing the levels of cardiac enzymes CPK-MB and cTnI in atrial septal defect (ASD) patients whose operative repair was done under cardiopulmonary bypass (CPB) using beating heart technique with and without the application of aortic cross clamp. Materials and Methods: This study was carried out in the Department of Cardiothoracic and Vascular Surgery in a Tertiary Care Hospital over a period of 2 years. A total of 60 atrial septal defect (ASD) patients were operated and repair of the defect was done under the CPB using beating heart technique. Aortic cross clamp was applied in 22 patients (Group-A) while 38 patients were operated without cross clamp (Group-B) during the procedure. Blood samples were collected 24 hours prior and 12 hours post procedure for the estimation of CPK MB and cTnI levels. Results: Mean age of the atrial septal defect patients was 23.83±10.97 years and 60% and 40% of the patients were females and children (age &lt; 18 years) respectively. Serum CPK-MB and cTnI l levels were in the normal range in all the patients before surgery and increased significantly post procedure. Twelve hours after surgery, the mean CPK-MB and cTnI levels were significantly low in Group-B patients compared to Group-A patients (CPK-MB: 56.39±23.55 U/L vs. 34.38±15.97U/L , p= 0.0004; cTnI: 9.37±4.97 ng/ml vs. 5.92±4.17ng/ml, p = 0.009). Conclusion: Post surgery CPK-MB and cTnI levels were significantly higher in ASD patients who underwent CPB surgery with aortic cross clamp compared to those in whom aortic cross clamp was not applied. Therefore, application of aortic cross clamp during the procedure induces greater levels of ischemic injury to the heart. IMC J Med Sci. 2023; 17(1): 001. DOI: https://doi.org/10.55010/imcjms.17.001 *Correspondence: Feroze Mohammad Ganai, Department of CVTS, Superspeciality Hospital, Shireen Bagh, Srinagar, Jammu and Kashmir, India. Email address: ferose999@yahoo.com

Proton magnetic resonance spectroscopy assessment of neonatal brain metabolism during cardiopulmonary bypass surgery.

Here, we report on the development and performance of a robust 3-T single-voxel proton magnetic resonance spectroscopy (1 H MRS) experimental protocol and data analysis pipeline for quantifying brain metabolism during cardiopulmonary bypass (CPB) surgery in a neonatal porcine model, with the overall goal of elucidating primary mechanisms of brain injury associated with these procedures. The specific aims were to assess which metabolic processes can be reliably interrogated by 1 H MRS on a 3-T clinical scanner and to provide an initial assessment of brain metabolism during deep hypothermia cardiac arrest (DHCA) surgery and recovery. Fourteen neonatal pigs underwent CPB surgery while placed in a 3-T MRI scanner for 18, 28, and 37°C DHCA studies under hyperglycemic, euglycemic, and hypoglycemic conditions. Total imaging times, including baseline measurements, circulatory arrest (CA), and recovery averaged 3h/animal, during which 30-40 single-voxel 1 H MRS spectra (sLASER pulse sequence, TR/TE = 2000/30 ms, 64 or 128 averages) were acquired from a 2.2-cc right midbrain voxel. 1 H MRS at 3T was able to reliably quantify (1) anaerobic metabolism via depletion of brain glucose and the associated build-up of lactate during CA, (2) phosphocreatine (PCr) to creatine (Cr) conversion during CA and subsequent recovery upon reperfusion, (3) a robust increase in the glutamine-to-glutamate (Gln/Glu) ratio during the post-CA recovery period, and (4) a broadening of the water peak during CA. In vivo 1 H MRS at 3T can reliably quantify subtle metabolic brain changes previously deemed challenging to interrogate, including brain glucose concentrations even under hypoglycemic conditions, ATP usage via the conversion of PCr to Cr, and differential changes in Glu and Gln. Observed metabolic changes during CPB surgery of a neonatal porcine model provide new insights into possible mechanisms for prevention of neuronal injury.

Bioinformatics Analysis Reveals Hub Genes That May Reduce Inflammation and Complications After Cardiopulmonary Bypass.

Cardiopulmonary bypass (CPB), though indispensable in many cardiac surgery procedures, has several undesirable consequences. The aim of this study was to identify potential genes that may reduce the inflammatory response and complications after CPB. The GSE132176 dataset was selected from the Gene Expression Omnibus (GEO) database and included 10 patients with tetralogy of Fallot and 10 patients with an atrial septal defect who underwent CPB surgery. TSV files were downloaded after GEO2R processing. Protein-protein interaction analysis of common differentially expressed genes (DEGs) was performed using the Search Tool for the Retrieval of Interacting Genes. Gene modules and hub genes were visualized in the protein-protein interaction network using Cytoscape. Enrichment analysis was performed for all important DEGs, modular genes, and hub genes. A total of 72 DEGs were screened, including two functional and one hub gene module. FOS modular genes were primarily enriched in NGF-stimulated transcription, spinal cord injury, and PID AP1 pathway. The ATF3 modular gene was mainly enriched in cytomegalovirus infection and transcriptional misregulation in cancer. Hub gene modules were primarily enriched in the PID AP1 pathway, positive regulation of pri-miRNA transcription by RNA polymerase II, and the PID ATF2 pathway. FOS, JUN, ATF3, and EGR1 were the four most important hub genes; the top three hub genes were involved in the formation of AP-1 and enriched in the AP-1 pathway. Finally, we measured the expression levels of these four genes in patients undergoing CPB via qRT-PCR, and the results were consistent with those obtained in bioinformatic analysis. FOS, JUN, ATF3, and EGR1 and the AP-1 pathway may play key roles in inflammation and complications caused by CPB.

Oral Aversion in Infants With Congenital Heart Disease: A Single-Center Retrospective Cohort Study.

Neonates undergoing cardiac surgery are at risk for oral aversion (OA). OA is not well described outside of the index hospitalization and impacts patients and families. We evaluated the prevalence of OA at 1 year old after neonatal cardiopulmonary bypass (CPB) surgery. Retrospective cohort study. Single quaternary care hospital. Our cohort included 157 neonates who underwent CPB surgery from 2014 to 2017 and had follow-up data available at 1 year old. None. Three feeding experts reviewed the medical record to define children with OA; 30% of charts were evaluated in triplicate for validation. Neonates with and without OA were compared in univariate analysis, and risk factors for OA were explored in a limited multivariable analysis. OA was present at 1 year in 37 patients (23.6%) and other feeding difficulties were present in an additional 29 patients (18.5%). Thirty-eight patients (24.2%) had a feeding tube, including 12 (7.6%) with a gastrostomy tube. Factors associated with OA at 1 year included total ICU days, duration of mechanical ventilation, total number of nil per os days, and number of postoperative days (PODs) until oral feeding initiation (all p < 0.0001). Number of POD until oral feeding initiation remained independently associated with OA at 1 year in multivariable analysis (adjusted odds ratio, 1.08; 95% CI, 1.04-1.12; p < 0.0001). Infants with any oral intake at discharge had lower odds of OA at 1 year (0.21; 95% CI, 0.08-0.5; p = 0.0003). At hospital discharge, 132 patients (84.1%) were taking some oral feeds, and 128 patients (81.5%) received tube feeding. OA and other feeding difficulties are common at 1 year old in neonates undergoing CPB surgery. Delayed exposure to oral intake may be a modifiable risk factor for OA and efforts to improve early oral feeding could lead to better functional outcomes.

CARDIOPULMONARY BYPASS IN PREGNANCY. A SINGLE-CENTER EXPERIENCE

The aim: Presentation of a single-center experience of cardiac surgery with cardiopulmonary bypass (CPB) in pregnant women with critical cardiac pathology. The possibility of minimally invasive technique in this group of patients were presented. Materials and methods: The present study included 19 cases of multidisciplinary care with CPB surgery in pregnant women in single center from December 2013 to December 2020. 8 patients underwent J-form median mini-sternotomy. Maternal and neonatal outcomes depending on the type of surgery (urgent or elective) were reviewed. Results: There were no negative maternal consequences; there were 4 perinatal losses (21%): three after urgent and one after elective interventions. All other pregnancies (n=15) finished successfully with the birth of healthy newborns. We compared some values in two groups (urgent and elective) of patients who underwent CPB surgery during pregnancy. Despite the variability in some parameters the difference between the groups was not significant. Follow-up was from 5 to 72 months (39.7±16.9) without negative consequences. Conclusions: Multidisciplinary team management is an effective strategy for pregnant women with cardiac pathology. Elective cardiac surgery in expert centers during pregnancy is a safe and effective option. Urgent CPB cardiac surgery during pregnancy increases the risk for the fetus. J-form median mini-sternotomy is a good option during pregnancy in high-experienced centers.

Abstract 9565: Quantitative Assessment of Neonatal Brain Perfusion by Ultrafast Power Doppler in the Operating Room

Introduction: The main challenge with cardiopulmonary bypass (CPB) surgery in newborns with congenital heart disease is to prevent ischemic brain injury impacting on the long-term neurodevelopmental outcomes. To date, no quantitative method is available to adapt the CBP parameters for optimal per-operative cerebral perfusion. Ultrafast power Doppler (UPD) is a new portative bedside technique to map and quantify cerebral perfusion. Our objective was to evaluate UPD for quantifying the variation of cerebral perfusion in neonates during CBP surgery. Methods: UPD was performed in 5 newborns with hypoplastic left heart syndrome undergoing a Norwood procedure and 5 age-matched healthy newborns. Using a 6.9 MHz linear array probe (11L, General Electric) connected to a programmable and portable ultrafast ultrasound scanner (Vantage 256, Verasonics Inc.), via a transfontanellar approach, six pre-defined brain imaging planes were acquired in sagittal and coronal views. Assessments were performed pre-operatively, during various perfusions states intra-operatively and 24-48 hours post-operatively. Global and regional cerebral blood volume (CBV) and resistivity index (RI) maps from UPD were obtained. Results: The baseline brain perfusion was the same for both groups (p=0.62). During CPB, whole brain and regional CBV decreases more than 50% compared to baseline and reaching approximately 25% of initial CBV during selective brain perfusion and during the final stages of bypass (Figure). RI maps shows intermittent overall decrease of vascular resistivities below 0.5 on bypass and selective brain perfusion before returning to baseline in post-op, reflecting an overall decrease of the cerebral vascular resistance during CPB. Conclusions: UPD demonstrates variation in cerebral vascular resistance and blood volume in neonates undergoing CPB surgery. UPD paves the road for optimization of CPB parameters in neonates undergoing cardiac surgery.

Plasma from patients undergoing coronary artery bypass graft surgery does not activate endothelial cells under shear stress in vitro.

Background:Cardiac surgery with cardiopulmonary bypass (CPB) is commonly associated with acute kidney injury, and microvascular endothelial inflammation is a potential underlying mechanism. We hypothesized that pro-inflammatory components of plasma from patients who underwent coronary artery bypass graft surgery with CPB induce endothelial adhesion molecule expression when incorporating altered shear stress in the in vitro model.Methods:The clinical characteristics and markers of systemic inflammation and kidney injury were analyzed pre and postoperatively in 29 patients undergoing coronary artery bypass grafting with CPB. The effects of tumor necrosis factor (TNF)-α and patient plasma on the expression of endothelial inflammation and adhesion markers were analyzed in vitro.Results:Plasma TNF-α was elevated 6 h postoperation (median: 7.3 pg/ml (range: 2.5–94.8 pg/ml)). Neutrophil gelatinase-associated lipocalin in plasma peaked 6 h (99.8 ng/ml (52.6–359.1 ng/ml)) and in urine 24 h postoperation (1.6 ng/mg (0.2–6.4 ng/mg)). Urinary kidney injury molecule-1 concentration peaked 24 h postoperation (0.5 ng/mg (0.2–1.2 ng/mg). In vitro, the expression of E-selectin was induced by 20 pg/ml TNF-α. In addition, the expression of interleukin-8, intercellular adhesion molecule-1, and vascular cell adhesion molecule-1 was induced by 100 pg/ml TNF-α. Compared to healthy control plasma exposure, postoperative plasma did not increase the expression of markers of endothelial inflammation and adhesion under shear stress in vitro.Conclusion:Patients undergoing CPB surgery showed mild systemic inflammation and kidney injury. However, the plasma components did not stimulate endothelial inflammation and adhesion molecule expression in vitro.

Feeding intolerance and risk of poor outcome in patients undergoing cardiopulmonary bypass surgery.

We conducted a prospective, observational study to determine the incidence of feeding intolerance (FI) within 7 d of initiating enteral nutrition (EN) in patients undergoing cardiopulmonary bypass (CPB) and to evaluate the association between FI and a poor prognosis. Patients who underwent CPB surgery at Fujian Medical University Union Hospital between March 2020 and June 2020 were enrolled. According to the presence or absence of FI within 7 d after EN, patients were divided into FI and non-FI groups. According to the occurrence of a poor prognosis (death, gastrointestinal haemorrhage, acute kidney injury, liver insufficiency, neurological events (cerebral infarction, cerebral haemorrhage and epilepsy) and prolonged mechanical ventilation (> 48 h)), patients were divided into poor prognosis and good prognosis groups. The mean age of the 237 CPB patients, including 139 men and ninety-eight women, was 53·80 (sd 12·25) years. The incidence of FI was 64·14 %. Multivariate logistic regression analysis showed factors independently associated with poor prognosis after CPB included FI (OR 2·138; 95 % CI 1·058, 4·320), age (OR 1·033; 95 % CI 1·004, 1·063), New York Heart Association (NYHA) class III/IV cardiac function (OR 2·410; 95 % CI 1·079, 5·383), macrovascular surgery (OR 5·434; 95 % CI 1·704, 17·333) and initial sequential organ failure assessment score (OR 1·243; 95 % CI 1·010, 1·530). Thus, the incidence of FI within 7 d of EN after CPB was high, which was associated with a poor prognosis.

Lung protective ventilation in infants undergoing cardiopulmonary bypass surgery for congenital heart disease: A prospective randomized controlled trial.

Lung protective ventilation (LPV) has been applied to surgical adults with normal pulmonary function for optimizing mechanical ventilation and reducing postoperative pulmonary complications. Few studies have reported the use of LPV in infants undergoing cardiac surgery with cardiopulmonary bypass (CPB). To explore safety and effectiveness of LPV in infants undergoing CPB surgery for congenital heart disease (CHD). Included in this study were 77 infants who underwent CPB surgery for CHD from November 2017 to September 2018. They were randomized into the LPV group and conventional ventilation (CV) group. In the LPV group, small-tidal-volume (6-8ml/kg) ventilation, lung recruitment by PEEP increment to the maximum level of 15cm H2 O after CPB, and individualized optimal PEEP titration were applied. In the CV group, traditional tidal volume (10-12ml/kg with zero PEEP) was applied. The primary outcome was the ratio of arterial partial pressure of oxygen to inspiratory oxygen fraction (PaO2 /FiO2 ). The secondary outcomes were respiratory dynamic parameters, hypoxemia, prognostic indexes, and postoperative pulmonary complications. PaO2 /FiO2 in the LPV group (416.86, 95%CI: 381.60-452.12) was significantly higher than that in the CV group (263.37, 95%CI: 227.65-299.09) after intervention (P<.001). There was a significant difference in the trend of change in dynamic compliance, alveolar-arterial oxygen difference, arterial-end-expired carbon dioxide difference, driving pressure, and respiratory index between the two groups at different time points from weaning from CPB to 2hours after operation. There was no significant difference in PaO2 /FiO2 , alveolar-arterial oxygen difference, respiratory index, and dynamic compliance 2hours postoperative and in the incidence of postoperative pulmonary complications, prognostic indexes between the two groups. LPV could be used safely in infants undergoing CPB in that it can improve oxygenation, alveolar aeration, and dynamic compliance, and reduce driving pressure, pulmonary shunting, and dead space. Its effect on oxygenation, pulmonary gas exchange, and pulmonary compliance was relatively short, and had less impact on postoperative pulmonary complications and prognosis.

Influence of hemoadsorption during cardiopulmonary bypass on blood vesicle count and function

BackgroundExtracorporeal circulation during major cardiac surgery triggers a systemic inflammatory response affecting the clinical course and outcome. Recently, extracellular vesicle (EV) research has shed light onto a novel cellular communication network during inflammation. Hemoadsorption (HA) systems have shown divergent results in modulating the systemic inflammatory response during cardiopulmonary bypass (CPB) surgery. To date, the effect of HA on circulating microvesicles (MVs) in patients undergoing CPB surgery is unknown.MethodsCount and function of MVs, as part of the extracellular vesicle fraction, were assessed in a subcohort of a single-center, blinded, controlled study investigating the effect of the CytoSorb device during CPB. A total of 18 patients undergoing elective CPB surgery with (n = 9) and without (n = 9) HA device were included in the study. MV phenotyping and counting was conducted via flow cytometry and procoagulatory potential was measured by tissue factor-dependent MV assays.ResultsBoth study groups exhibited comparable counts and post-operative kinetics in MV subsets. Tissue factor-dependent procoagulatory potential was not detectable in plasma at any timepoint. Post-operative course and laboratory parameters showed no correlation with MV counts in patients undergoing CPB surgery.ConclusionAdditional artificial surfaces to the CPB-circuit introduced by the use of the HA device showed no effect on circulating MV count and function in these patients. Larger studies are needed to assess and clarify the effect of HA on circulating vesicle counts and function.Trial registration ClinicalTrials.Gov Identifier: NCT01879176; registration date: June 17, 2013; https://clinicaltrials.gov/ct2/show/NCT01879176